Download MINOR

MINOR
MEDICAL AND DENTAL HISTORY
Please answer ALL questions to the best of your knowledge. The information requested below is very important. Please
make it as complete and accurate as possible, as it will help us to provide the best possible health service. This
information form becomes part of our permanent records and will be held in strict confidence. For patients of parents,
complete this information for your child. Please update your medical history every 6 months.
Name: ________________________________________________ Date of Birth: _________________ Age: _______
DENTAL
1. *Please describe the problem you would like to see corrected with orthodontics: ________________________
_________________________________________________________________________________________________________
 YES  NO
2. Does anyone in the family have a similar dental or facial condition?
3. Who referred you to our office? ______________________________________________________________________
4. Name of family dentist: __________________________________________
Phone #: _____________________ Address: _____________________________________________________________
5. Date of last dental appointment: __________________
6. How frequently does patient brush? ____________ Floss? _________________
 YES  NO
7. Have the patient’s teeth ever been injured in the past?
If YES, describe: __________________________________________________________________________________
8. Has the patient ever had any of the following habits:
Grinding / Clenching
Lip biting/sucking
Nail biting
Tongue thrusting
Thumb/ finger sucking
Mouth breathing
YES






NO






9. Rate parent’s concern for correction of the orthodontic problem:
 Very concerned
 Concerned
 Indifferent
 Opposed
 Uncertain
 Very concerned
 Concerned
 Indifferent
 Opposed
 Uncertain
 Excellent
 Good
 Fair
 Poor
 Uncertain
10. Rate patient’s concern for correction of the orthodontic problem:
11. How do you think the patient will react to orthodontic treatment?
12. Has the patient ever had a consultation for orthodontic treatment before?
 YES  NO
 YES  NO
13. Has the patient ever had braces or any other orthodontic appliances?
If YES, describe: __________________________________________________________________________________
MEDICAL
1. Name of physician: ____________________________________________________
Phone #: _______________________________ Address: ___________________________________________________
2. Date of patient’s last physical exam: ______________________
3. Please check if the patient is currently taking any of the following medications:
Antibiotics
Anticoagulants
Anticonvulsants
Antipsychotics
YES




NO




YES
NO
Cortisone, Other steroids 

Aspirin


Insulin


Other: _____________________________________
4. Is there a past history of the patient taking any of the above medications?
 YES  NO
If yes, please describe:________________________________________________________________________________
CONTINUED ON BACK PAGE →
5. Is the patient allergic to any of the following:
6.
YES
NO




YES
NO
Local anesthetics


Codeine

Penicillin

Latex
Does the patient have a history of:
YES
NO
YES
NO
Aspirin


Barbiturates/sedatives 

Sulfa drugs


Other allergies: _____________________________
Anemia


Heart problems


Asthma / emphysema 

Hepatitis/liver disease 

Arthritis


High blood pressure 

Autism


Kidney disease


Bone / joint problems 

Mitral valve prolapse 

Brain injury


Persistent cough


Cancer:


Coughing up blood 

_______________________________
Psychiatric problems 

Cerebral palsy


Rheumatic fever


Diabetes


STD: _________________

Emotional difficulties 

Sickle cell anemia


Epilepsy / seizures


Speech difficulties


Fainting or dizziness


Stomach ulcer


Headaches


Thyroid disease


Hearing difficulties


Tuberculosis


HIV+ / AIDS


Other: _______________________________________
7. Does the patient require antibiotics prior to certain dental treatments?
 YES  NO
CONSENT STATEMENT
Elaine V. Sunga, DDS, Inc. and staff are hereby authorized to perform such dental and related surgical or medical
treatments as deemed necessary to adequately provide such treatment for the above named patient.
The undersigned understands and agrees that each patient’s records and materials pertinent to his/her treatment
become property of Elaine V. Sunga, DDS, Inc. Dr. Elaine V. Sunga and staff are authorized to furnish, from the patient’s
record, requested information of pertinent nature or excerpts thereof, to any approximate insurance company for the
purpose of obtaining payment of the account of the patient. By signing, I also give my permission for the use of
orthodontic records made in the process of examinations, treatment, and retention for purposes of professional
consultations, research, education, or publication in professional journals by Dr. Elaine V. Sunga.
I have read the preceding information fully, and understand it, and agree to comply with all rules and regulations for
patient processing and treatment. To the best of my knowledge, the preceding answers are complete and accurate.
_________________________________________________________
Signature of Parent / Guardian or Person Authorized to Consent for Patient
_________________________________
Date
________________________________________________________
Witness Signature
_________________________________
Date
OFFICE USE ONLY:
Date: _________________________
Health history reviewed by: _______________________________________
COMMENTS: ___________________________________________________________________________________________
_________________________________________________________________________________________________________
Health History Updates: (every 6 months while in active treatment)
Any changes in the patient’s health or medications? Y N
Any changes in the patient’s health or medications? Y N
Comments: ________________________________________
Comments: ________________________________________
___________________________________________________ ___________________________________________________
Signature: _______________________ Date: ____________
Signature: _______________________ Date: ____________
Doctor Signature: __________________ Date: ____________
Doctor Signature: __________________ Date: ____________
Any changes in the patient’s health or medications? Y N
Any changes in the patient’s health or medications? Y N
Comments: ________________________________________
Comments: ________________________________________
___________________________________________________ ___________________________________________________
Signature: _______________________ Date: ____________
Signature: _______________________ Date: ____________
Doctor Signature: __________________ Date: ____________
Doctor Signature: __________________ Date: ____________